Waiting for care

Abstract

Objective

To describe the experiences of a group of new immigrants and caregivers of new immigrants who were subject to the 3-month waiting period for the Ontario Health Insurance Plan and needed to access health care services during that time.

Design

Qualitative study using a phenomenologic framework.

Setting

Participants were recruited through the Scarborough Community Volunteer Clinic in Toronto, Ont. Interviews were conducted in person at the clinic or by telephone.

Participants

Seven participants were interviewed who themselves needed to access health care during the 3-month waiting period for the Ontario Health Insurance Plan or who were caring for someone who did.

Methods

Seven semistructured, in-depth interviews were conducted using an interview guide; these were recorded and transcribed verbatim. Data were analyzed for themes to arrive at the essence of the participants’ experiences.

Main findings

Participants believed that there was a lack of clear information and a lack of help from officials. Other common themes included poor social situations, financial loss or threat of financial loss related to health care, a choice to delay seeking care owing to cost, difficulty accessing alternative care, and appreciation for those who advocated on their behalf. Other themes that arose included emotional hardship, poor health outcomes or threat of poor health outcomes resulting from not seeking care, the importance and unpredictability of health, as well as negative impressions of Canada as a country as a result of the negative experience of seeking care.

Conclusion

New immigrants to Ontario who need to access health care services during the 3-month waiting period for provincial health insurance and the caregivers of such newcomers can have potentially very negative experiences. They might be unable to access care without financial barriers and might, therefore, choose to delay seeking health care until the end of the waiting period; this can lead to emotional hardship for themselves and their caregivers as well as to potentially poor health outcomes. This potential for an overwhelmingly negative experience for some new immigrants to Ontario might lend support to the argument that this policy be eliminated.

Canada accepts approximately 250 000 new permanent residents a year including economic immigrants (49.0% in 2011), family class immigrants (34.6%), refugees (11.2%), and others.¹ The largest proportion land in Ontario (40.0% in 2011), followed by Quebec (20.8%) and British Columbia (14.0%).¹ These 3 provinces, as well as the Yukon, impose waiting periods lasting 2 to 3 months (varying by province and territory) for access to provincial or territorial health insurance for landed immigrants. Other provinces and territories in Canada do not impose such waiting periods.^2–5 In Quebec, the waiting period has exemptions for pregnancy, serious infectious disease, victims of domestic violence, and immigrants from certain European countries.³ Until recently, New Brunswick had a waiting period policy, but in February 2010 New Brunswick joined the rest of Canada by eliminating its 3-month waiting period.^6,7 Ontario’s waiting period policy has been in place since 1994. This policy applies to new immigrants, returning Canadians, and new residents from other provinces. However, those from other provinces are covered by insurance from their home province to bridge this gap. Other groups that have been classified as permanent residents, such as government-assisted refugees and privately sponsored refugees, receive health insurance upon arrival in Ontario (through the Ontario Health Insurance Plan [OHIP] or through the Interim Federal Health Program, a federally funded program for refugee claimants).^8,9

Case vignette

A 39-year-old Nigerian woman had lived in the Netherlands for 12 years before coming to Ontario as a landed immigrant. She applied for immigration in 2006, and when she learned of her acceptance in 2009, she was in her third trimester of pregnancy with gestational diabetes. She read materials provided to her by immigration, which spoke of Canada’s universal health care system. Aware of the importance of her and her baby’s health, the day after her arrival to the country, she proceeded to the OHIP office where she was informed she would have to wait 3 months before getting access to health insurance. She attempted to find private insurance but was denied owing to a pre-existing condition (pregnancy). Within a week of her arrival in Canada, she went into labour, required a cesarean section, and was left with a bill of $12 000, which she is now paying in monthly installments.

While there is a paucity of peer-reviewed literature addressing the waiting period policy in Ontario, there is substantial evidence pointing to poorer health outcomes for those who are medically uninsured in Canada, often focusing on those who are undocumented.^10–13 Research from the United States identifies that those who are uninsured delay seeking care and present with later stages of disease.^14,15 Poor health outcomes resulting from the 3-month waiting period in Ontario have been documented in the gray literature,^16–19 and a study analyzing the patient population at the Scarborough Community Volunteer Clinic (SCVC) in Toronto, Ont, a free clinic that opened in 2000 to serve medically uninsured immigrants and refugees in the Greater Toronto area, found that 36% of patients at the SCVC were landed immigrants in the 3-month waiting period, suggesting this population is indeed attempting to access free care somewhere.²⁰ It is unclear how many immigrants purchase private insurance or access care and pay out of pocket during the waiting period.

A policy paper by the Ontario Medical Association from April 2011 discusses the poor access to care for new immigrants in Ontario, the negative implications for their personal health, effects on public health, and implications for physicians who have to ask for payment when providing care.²¹ The paper states there is evidence to suggest that care is often delayed for the duration of the 3 months, resulting in the same financial cost to the public system, only 3 months later, as evidenced by an increase in physician billings when immigrants are in their fourth month of stay.^21,22 The paper calls for an end to the 3-month waiting period policy.

This study addresses a gap in the literature around the experiences of new immigrants who need to access health care services during the 3-month waiting period. It describes the experiences of a sample of new immigrants in Ontario and their caregivers who sought health care at the SCVC during this time. This is an important issue for family physicians in all practice settings as the primary care providers for the community, given this barrier to access for a portion of our patient population. While this study focuses on individuals undergoing the 3-month waiting period in Ontario, the results are relevant for physicians and policy makers in Quebec, British Columbia, and the Yukon, where such policies also exist.

METHODS

Semistructured in-depth interviews were conducted with 7 participants. They were either themselves new immigrants to Ontario who experienced the 3-month waiting period and needed to access health care services during that time, or were immediate caregivers for such individuals. All participants had sought care at the SCVC within the past 5 years, and most had done so within the past year. Interviews were conducted between December 2009 and January 2010. Participants were recruited through the SCVC, a volunteer-run clinic serving those without health insurance in the Greater Toronto area. Ethics approval was obtained through the Scarborough General Hospital. Each potential interviewee had to have undergone the 3-month waiting period and required health care services during that time or have been the immediate caregiver of such an individual. An attempt was made to choose participants with diverse ages and geographic origins. This was explained to a key contact through the SCVC clinic who recruited participants. The participants were given an explanation of the study and had the option of refusing participation. Volunteers at the SCVC identified and contacted 9 potential participants and introduced the idea of the study; 7 of these individuals were interviewed, at which point there was believed to be a saturation of themes.

A phenomenologic framework was employed and all interviews were conducted, transcribed, and analyzed by the primary investigator (R.G.). An interview guide was used, but it allowed for extensive probing. Two interviews were conducted by telephone for the convenience of the interviewees, and the remainder were performed face to face. The interviews lasted 20 to 30 minutes and were recorded. The study sample is described in Table 1. In 4 cases, the participant interviewed was the caregiver of a new immigrant who experienced the 3-month waiting period (child or elderly parent). Five interviews were conducted in English without translation. One was conducted in Urdu, known to both the participant and the interviewer, and one was conducted using a community member interpreting Dari.

Table 1.

Description of study sample

VARIABLE	NO.
Sex
• Male	2
• Female	5
Age range, y
• 0–18	3
• 19–30	2
• 31–50	1
• > 50	1
Ethnicity
• African	4
• South Asian	1
• East Asian	1
• Middle Eastern	1

Transcription data were scanned to extract important statements and were classified into common themes. These common themes were then translated into important items of meaning or short phrases that expressed the content of that theme. These items of meaning were then aggregated into clusters, listed below. Taken together, these clusters allowed for a description of the experience of these new immigrants and their caregivers who needed to access health care services during the 3-month waiting period for health insurance in Ontario. The process of analysis was ongoing as interviews were being conducted, allowing for the interviewer to note patterns emerging and decide, upon completion of 7 interviews, that the same themes were consistently re-emerging, and no further interviews were required.

FINDINGS

Several common themes emerged from the experiences of the 7 participants who needed to access health care services during the 3-month waiting period for themselves or someone they were caring for.

Lack of clear information and lack of help from officials

Most participants were unaware of the 3-month waiting period policy before their arrival. Some were informed by a family member who had previously immigrated, but most learned of the policy on arrival at an OHIP office. Most participants indicated there was unclear or misleading information presented by immigration materials and officials, and a lack of help from officials at the OHIP office. None of those undergoing the waiting period had private insurance, reasons for which included lack of knowledge that it was necessary, inability to pay, or denial by the insurance company. A 39-year-old Nigerian woman who arrived in Ontario in her third trimester of pregnancy stated,

They don’t inform you before coming to Canada that there is a 3 months waiting period. They do send you an immigration package. It talks about free health care; it doesn’t talk about a 3 months waiting period in it .… And then, at the OHIP office they don’t have any idea about anything. All they know is that you’re not allowed coverage until after 3 months, and you don’t get anyone to talk to over there too.

Poor social situation

Most participants described poor social circumstances upon arrival in Canada, including issues with finances, housing, and employment. The father of a 7-year-old boy with congenital heart disease arrived in Canada before his family, and described his family’s initial housing situation:

For 1 month, I was downtown, just in 1 room. When they [got] here, we live[d] in a basement without a heater, without enough electric[ity]; so after that I had to find [just] ... any house ... we ha[d] to get out ... at the end of the month .… Money was a problem.

Financial harm or threat of financial harm

Most participants spoke of a fear of financial harm from accessing health care services and one participant suffered considerable financial harm from accessing them. She incurred hospital and physician bills totaling $12 000 after going into labour during the waiting period. She stated,

The hospital and the charges, it’s a whole lot of money. The person just comes to the country, you haven’t settled yet, you haven’t got a job yet, and then you start by having bad credit, owing everywhere; it’s ... financially, it’s not correct .… They create a world of debt which one cannot imagine, how [it can] be solved. And that to me, for an immigrant, is disastrous.

Several participants were asked to pay for care. On some occasions participants did pay, but usually they chose to stop trying to get care because of the associated cost.

Delay seeking care

All participants delayed seeking care owing to the 3-month waiting period. All participants agreed that access to OHIP on arrival would have meant that they sought care earlier. A 59-year-old man from China hid his symptoms of stroke from his daughter and waited 3 months before seeking care owing to cost. A 7-year-old boy with transposition of the great arteries waited 3 months in congestive heart failure until the end of the waiting period for surgery. A 2-year-old girl found to be HIV-positive during immigration screening waited 3 months before seeing a specialist for a care plan and counseling. The father of a 4-month-old girl with a fever and cough stated,

I feel bad; I feel sad because I cannot afford to pay from my pocket to go to the hospital, to go to the doctor .... I was upset because I said I’m not working .… How can I go to [the] doctor? How can I afford to go to [the] doctor?

Difficulty accessing alternative care

All participants attempted to circumvent and mitigate the cost barrier. They reported multiple visits in order to obtain health care, as often the first point of care required payment. Participants described difficulty in obtaining care including ill treatment from health care staff. The mother of the 2-year-old girl was informed of her daughter’s HIV-positive status over the telephone by immigration officials and was not connected with any resources to deal with this diagnosis: “They just call me in the immigration, and they tell me that my daughter ... has AIDS .… They just call me and let me know. So I didn’t know; I was shocked.”

Importance of advocacy

All participants highlighted the importance of and their gratitude toward community members, organizations, and clinics that provided care or helped them find care. A mother who took her children to the SCVC during the waiting period after being unable to pay elsewhere stated, “So then, somebody told me that I should go to, there is a clinic, a community clinic, this clinic that should help me. So then I came to this clinic; they help[ed] me in those 3 months.”

Emotional hardship

Every participant conveyed experiences of emotional hardship resulting from the 3-month waiting period. The most common sentiments were worry and fear. Others included sadness, frustration, guilt, a sense of injustice, helplessness, feelings of abandonment, and feelings of being misled. Several caregiver participants expressed guilt over an inability to care for their dependents. One participant spoke of her 59-year-old Chinese father who had a stroke:

I really feel frustrated and big pressure on me .… Yeah, and I [was] really scared; if something worse happened to my father, I will regret [it for my] whole life .… [M]y husband was laid off, so there was a lot of financial problems. And at that time, I [didn’t] know how much my father[‘s health care would] cost, so I also [felt] very guilty.

The mother of the 2-year-old Congolese girl found to have HIV stated:

It [was] really frustrating, upsetting, what I experience[d] for that 3 months waiting; it was very hard. For me, I don’t even have a word to explain that. I was crying all day, looking [after] my children, 3 of them; nobody could eat.

Poor health outcomes or threat of poor health outcomes

The potential for a poor health outcome due to the waiting period was a serious concern for participants. In the case of the 59-year-old gentleman who hid the symptoms of his stroke for fear of cost, a potentially avoidable poor health outcome was incurred. His daughter described the effects: “After the stroke, he changed a lot. He doesn’t like to speak a lot now. He only stays in his room by himself. Also, sometimes, he gets very angry. Sometimes he [will forget] something.”

Care was delayed for a 4-month-old girl with respiratory distress, a 7-year-old boy with congenital heart disease in congestive heart failure, and a 26-year-old pregnant woman with severely elevated blood pressure; in each case the delay had the potential for consequent poor health outcomes.

Importance and unpredictability of health

Many participants spoke to the importance of health as something of high value as well as something that is unpredictable. They expressed a sense of confusion or frustration around the existence of a waiting period. One participant stated, “If for the first 3 months you can’t go to hospital until the day after, meaning the first 3 months you shouldn’t be sick, it’s crazy. You can be sick at any time.”

Association of negative experiences with Canada

Several participants described how their experiences left them with a negative view of Canada. In the case of the 59-year-old man from China, he and his wife stated they were considering returning home after the negative experience they had with the 3-month waiting period. The mother of the 2-year-old girl found to be HIV positive stated, “It wasn’t fair, because if you come here to Canada, the country sponsors you to come here, so they should provide everything. I think it’s not fair, especially for people who have children.”

DISCUSSION

The experiences of the new immigrants and caregivers interviewed in this study who needed to access health care services during the 3-month waiting period for OHIP demonstrate the potential for strongly negative experiences. This finding adds to cases found in the gray literature.^16–19 Proponents of the 3-month waiting period policy have described it as a cost-saving measure that prevents abuse of the system.¹⁹ A study demonstrating the increased rates of physician billing in the fourth month of an immigrant’s stay suggests that costs of delayed visits are merely captured at a later time.²² In fact, delays in seeking care could result in worse presentation of disease, as suggested by research from the United States, leading to a potentially higher long-term cost in caring for a population who will be covered under public health insurance in a matter of months.^14,15 As well, the healthy immigrant effect describes the phenomenon of immigrants being healthier than their Canadian counterparts of the same age and sex, which might suggest a lower cost to insure this population in the first place.²³

Another common argument favouring inaction on this policy is the availability of private insurance, emergency departments, and community health centres (CHCs), a primary care model that has access to funding for patients who are uninsured.²⁴ A federal parliamentary report, Immigration Status and Legal Entitlement to Insured Health Services, from October 2008 states that private insurance is often denied for those in the waiting period and, if not, often covers emergency care only.²⁵ The same report states that services at CHCs are often unavailable owing to long waiting lists, suggesting that these are not good solutions.²⁵

At the announcement of the elimination of the 3-month waiting period in New Brunswick, the health minister expressed that “Removing the three-month waiting period is the right thing to do.”⁶ For reasons related to public health safety, personal health consequences, and the possibility cost would not increase, the Ontario Medical Association, the Toronto Board of Health, the Registered Nurses’ Association of Ontario, and others have proposed a complete elimination of this policy for both new immigrants and returning Canadians.^20,21,26,27

Limitations

This study describes the experiences of a group of new immigrants and their caregivers in the 3-month waiting period for OHIP in Ontario. This allows for an in-depth understanding of the experiences of this group but does not seek to quantify the prevalence of landed immigrants who need to access health care during their waiting period and have negative experiences during this process. This study also does not look at the 3-month waiting period as it applies to “returning Canadians” who have spent more than a defined period of time outside of the country.^2–5 There is also an opportunity for similar research to be conducted to analyze the experiences of those subject to the waiting periods in British Columbia, Quebec, and the Yukon. As well, a cost analysis of the removal of such a policy would be a useful endeavour for future research.

Conclusion

New immigrants to Ontario who need to access health care services during the 3-month waiting period for health insurance and the caregivers of such immigrants can potentially have very negative experiences. They might choose to delay seeking care, risking emotional hardship, potentially poor health outcomes, and various other consequences. Existing information suggests there is a lack of viable options such as private insurance or care at CHCs for this population. Concerns pertaining to the effects of this policy on public health, personal health, and fairness have led to a push for removal of this policy by various organizations. This study seeks to describe the experiences of some new immigrants and their caregivers who went through the waiting period and required the use of health care services during that time. Their negative experiences demonstrate the potential negative consequences of this policy and support its removal.

EDITOR’S KEY POINTS

• New immigrants to Ontario who need to access health services during the 3-month waiting period for the Ontario Health Insurance Plan might delay seeking care for fear of financial implications and they might experience emotional burden and the threat of poor health outcomes when they do so.

• Such newcomers and their caregivers might have difficulty accessing clear information, have poor social circumstances, and appreciate those who advocate for finding care.

• New immigrants to Ontario waiting for health insurance coverage can potentially have very negative experiences, which might lend support to the argument that this policy should be eliminated.

POINTS DE REPÈRE DU RÉDACTEUR

• Les immigrants nouvellement arrivés en Ontario qui ont besoin de services de santé durant la période d’attente de 3 mois pour obtenir la protection de l’Assurance-santé de l’Ontario risquent de repousser la date de leur consultation par crainte de difficultés financières, d’être affectés sur le plan émotif, et d’avoir des conséquences indésirables pour leur santé lorsqu’ils le font.

• Il semble que les nouveaux immigrants et les personnes qui les soignent aient de la difficulté à obtenir des renseignements clairs, qu’ils soient socialement défavorisés mais qu’ils apprécient les efforts de ceux qui les aident à obtenir des soins.

• Les immigrants nouvellement arrivés en Ontario en attente de l’assurance santé peuvent vivre des expériences très difficiles, ce qui pourrait plaider en faveur de l’élimination de cette politique.